Definition/Introduction
Personal protective equipment (PPE) came into the spotlight at the height of the COVID-19 pandemic, but these important materials and practices have been protecting healthcare providers for years. Regulation of PPE standards usually falls to the Centers for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA). The availability, application, and disposal of PPE play an essential role in a healthcare system's ability to care for patients safely.[1] Part of standard precautions, PPE provides a barrier to minimizing workplace hazards that healthcare providers encounter from harmful exposures. Chemical, biological, radiological, and nuclear contamination threats are encountered throughout healthcare. This article discusses the application of PPE in relation to healthcare. See Table. Personal Protective Equipment Clinical Presentations and Recommended Precautions.
Issues of Concern
Types of Personal Protective Equipment
Commonly worn PPE includes a gown, gloves, masks, respirators, and face shields or goggles. Understanding the limitations and proper wearing of PPE is essential to ensuring safe practices. Specific gloves offer differing levels of standards for infection prevention. One commonly used metric in glove safety evaluation is the acceptable quality level (AQL). A lower AQL means a higher quality glove with less micro-perforation potential and fewer pinholes in the glove product. The FDA generally recommends a minimum AQL level of 1.5 for surgical gloves and 2.5 for medical exam gloves.[2]
Surgical procedural evidence supports using two layers of gloves as an infection prevention technique.[3][4] Surgical procedures also necessitate using sterile gloves, which have been treated to eliminate microbes.
The availability of appropriate gowns can prevent the spread of infection. Medical gowns follow the American National Standards Institute (ANSI), the Association of the Advancement of Medical Instrumentation (AAMI), and the Food and Drug Administration's (FDA) ANSI/AAMI PB70 standards for medical gowns. The ANSI/AAMI PB70 has four levels of fluid barrier protection.[5]
USP 800 guidelines promote safety by outlining gown standards for handling hazardous drugs. Following suggested guidelines for PPE in the appropriate setting, whether using sterile gowns for surgery or non-sterile gowns for contact exposure, will ensure the safety of both healthcare workers and patients.[6][7]
Loosely woven cloth masks provide the least respiratory protection, while National Institute for Occupational Safety and Health (NIOSH) approved respirators offer the most protection.[8][9] A key component of mask protection involves the proper fitting of masks.[10] All healthcare workers should be fit tested if required to use respirators, including N95 masks.[11][12]
If fit testing cannot be completed, then a NIOSH-approved powered air purifying respirator (PAPR) can be considered based on institutional and local regulatory requirements.[13][14][15] The COVID-19 pandemic created a high demand for face coverings with limited consistent standards comparing different products. The American Society for Testing and Materials (ASTM) and NIOSH updated barrier face covering standards, ASTM F5302-21, allowing comparison between different barrier face coverings.[16]
Standard Precautions
Standard precautions serve as a framework all healthcare providers should follow as part of an initial approach to limiting exposure. These preventative steps should be considered for every patient encounter.[17][18][19][20]
Standard precaution components are listed here:
Hand hygiene, including hand washing, regardless if gloves are worn, before and after contact with a patient or bodily fluids
[21][22][23]Appropriate use of PPE, including gown, gloves, and eye protection, especially if there is a risk of bodily fluid exposure
Respiratory/cough etiquette to prevent droplet transmission of respiratory pathogens
Patient placement with consideration for single patient rooms and routes of transmission for specific infectious agents
Safe needle and instrument handling
Infection Prevention
PPE infection prevention recommendations can be categorized into specific transmission-based precautions. Following these recommendations, in addition to standard precautions, can protect healthcare providers and patients from disease infection. Clinical presentations giving concern for certain organism exposures require different standards of transmission prevention.[24][25] Please see Table 1.[26][27]
Contact precautions require the use of a gown and gloves in clinical situations involving organisms spread by direct or indirect contact with a patient or patient's environment. For example, clinical scenarios involving wound drainage, fecal matter, or other bodily discharge exposure would suggest using contact precautions.[28][29]
Droplet precautions should be utilized in respiratory illness where close mucous membrane contact or respiratory droplet exposure may occur. Droplet precautions should include standard precautions, eye protection, and a mask. Generally, pathogens requiring droplet precautions do not remain infectious over extended distances. Eye protection and an N-95 mask or higher-level respirator should be utilized with standard precautions in the setting of airborne precautions. Airborne pathogens have long-distance exposure potential that necessitates the need for special air handling and ventilation systems. These ventilation systems should meet the Architects Facility Guidelines Institute standards for airborne infection isolation rooms. Easily visible signs should be placed outside patient rooms and contact zones listing the required PPE for a specific patient encounter.[26]
Chemical and Nuclear Personal Protective Equipment
Healthcare providers may come into contact with harmful chemicals as part of day-to-day activity. Whether in the form of cleaning, pharmaceutical, or contamination, exposures are a risk at several points throughout regular workplace flow. In the event of exposure to workplace-stocked chemicals, Material Safety Data Sheets (MSDS) should be referenced for information specific to each chemical. Standard PPE should be utilized in the setting of chemical handling as defined by OSHA and CDC. Considerations should be made for areas of safe chemical handling, including adequate ventilation, safe handling areas, cleaning work surfaces, and spill procedures. In the scenario where a healthcare provider must enter a contaminated area with appropriate hazardous materials (HAZMAT), PPE must be utilized.[30][31][32]
HAZMAT equipment PPE recommendations follow OSHA standards as outlined by Levels A, B, C, and D. Different levels of protection are offered in each guideline, from the highest level of protection, Level A, including self-contained breathing apparatus (SCBA) to Level D least protective including standard precautions and appropriate work uniform. Level A PPE should be utilized when the hazardous substance requires the highest level of eye, skin, and respiratory protection.[33][34]
Level A PPE guidelines are also followed when entering areas of poor ventilation or when a substance has not yet been identified as appropriate for a lower level of protection. Level B PPE provides protection in areas requiring a high level of respiratory protection, including scenes with less than 19.5% oxygen or incompletely identified vapors/gasses. Level C PPE protection is appropriate in situations necessitating air-purifying respirators and contaminants which will not cause adverse harm through exposed skin. Level D PPE would be utilized when no known hazard is present in the atmosphere and contact or inhalation with hazardous levels is precluded by work functions. Other PPE may be included as defined by specific sceneries and OSHA recommendations. Part of the appropriate response to chemical exposure also includes decontamination processes in addition to proper disposal of used PPE.[35]
Recommendations for nuclear hazardous materials come from OSHA guidelines regarding events involving chemical, biological, radiological, or nuclear (CBRN) agents.[36] Recommendations for specific exposure risks can be found in relation to the area of contamination. Three zones of contamination are outlined in the recommendations, with the red zone being the area of most significant contamination and the green zone being the area of lowest contamination. Level A OSHA protection is usually recommended in a red zone. Yellow zone area of contamination PPE needs should be decided with consideration for air monitoring results, skin contact risk, and proximity of the event. Green zone contamination with CBRN agents is unlikely to occur.
OSHA Defined PPE
Level A: positive pressure full face-piece SCBA, encapsulating covering chemical protective suit, chemical-resistant outer gloves, chemical-resistant inner gloves, chemical-resistant boots with steel toe, disposable protective suit/gloves/boots
Level B: positive pressure full face-piece SCBA, chemical-resistant clothes with hood, chemical-resistant outer gloves, chemical-resistant inner gloves, chemical-resistant boots with steel toe
Level C: air purifying respirator, chemical-resistant clothes with hood, chemical-resistant outer gloves, chemical-resistant inner gloves, chemical-resistant boots with steel toe
Level D: gloves, coveralls, chemical-resistant boots/shoes with steel toe, safety glasses or chemical splash goggles
Radiologic PPE
Exposure to ionizing radiation can present a significant long-term health risk to healthcare providers. PPE should be available for healthcare providers working within radiation-exposure settings. Of particular importance, dose reduction with exposure to x-ray and gamma radiation can be achieved with proper PPE.[37][38][39] Providers practicing with X-ray and gamma radiation exposure, especially fluoroscopy and other image-guided procedure devices, should have access to a lead apron/vest, lead-lined glasses, lead-lined cap, and lead protection collar.[40][41][42][43]
Dose monitoring is required by OSHA Ionizing Radiation standards for workers who enter a high radiation area or restricted area or receive a dose in any calendar quarter more than 25% of the appropriate occupational limit.[44][45][46][47] OSHA standards for monitoring radiation exposure can be followed by wearing a person's passive dosimeter for exposure dose evaluation.[48][49]
Clinical Significance
Personal protective equipment implementation has become the standard of care for medical providers. The COVID-19 pandemic reshaped healthcare in many ways, including the increased emphasis on health practitioner safety in the presence of communicable diseases. PPE has been shown to prevent the spread of disease and preserve the health of individual practitioners. Following guidelines regarding the use of PPE sets a standard for all healthcare organizations to follow. Proper training is needed for PPE to be effective, including the appropriate application and removal of PPE.
Specific steps for putting on (donning) and taking off (doffing) pieces of PPE will be reviewed here. Not all components of PPE are required for each patient, and specific isolation precautions should be followed as appropriate.[50][51][52]
Suggested Sequence for Application of PPE
Donning of PPE should take place outside patient rooms.
Gown
Cover body from neck to knees, arms to wrists, and ensure gown wraps around the back
Tie neck and waist straps if available
Mask or Respirator
Place straps or ties around the head/neck
Adjust the flexible band to the nose bridge for proper fit
Fit-check respirator
Eye protection
Place eye protection on the face to ensure adequate protection of the face/eyes
May include goggles and/or a face shield
Gloves
Ensure application of gloves extends to cover the wrist of the gown
Suggested Sequence for Removal of PPE
Doffing of PPE should take place outside patient rooms. If a respirator is in use, do not remove the respirator until after exiting the patient room.
Gloves
Remove the first glove by grasping the palmar surface with the other gloved hand, and discard the first glove in the appropriate disposal container
Remove the second glove by sliding the fingers of the ungloved hand under the remaining glove at the wrist, and discard the second glove in the appropriate disposal container
Eye protection
Remove without touching the contaminated outside surface on the front of eye protection, and handle equipment by the strap or earpieces
Dispose of in the appropriate reprocessing or waste container
Gown
Release gown straps or ties
Touching inside of gown only, remove by pulling away from neck and shoulders
Turn the gown inside out
Place in an appropriate disposal container
Mask or Respirator
Do not touch the front or mouth area of the mask/respirator
Remove by releasing ties or straps around the back of the head
Discard in the appropriate disposal container
Nursing, Allied Health, and Interprofessional Team Interventions
Proper use of CDC and OSHA-recommended PPE within a healthcare setting prevents the spread of infectious pathogens between patients and providers. However, more expansive studies are needed to review current practices and policies.[53][54][55][56]
PPE also serves to help healthcare workers avoid harmful outcomes in the setting of exposure to CBRN agents. Adherence to PPE standards is multifaceted, with several components factoring into healthcare workers' ability and desire to follow PPE guidelines. Areas of concern include workplace culture, availability of PPE, training, trust in PPE, and communication of hospital guidelines.[57]
Administrative teams are often responsible for ensuring the availability of PPE resources. Infection prevention teams that monitor and track hospital personal standard precaution use may increase compliance.[58][59] [Level 2] Following suggested doffing protocols can decrease the risk of potential contamination after providing care.[60][61] [Level 2]
PPE has been shown to offer protection against respiratory infections, especially COVID-19.[62] [Level 1]
